5. Inductions

BlueScope Passport *Yes No

Site Induction 1 *Yes No

Site *

Date *

Expiry *

Attachment *

Site Induction 2 *Yes No

Site *

Date *

Expiry *

Attachment *

6. Fitness for Work

It is important that you be medically fit to perform the duties associated with the occupation or positions you are registering for. Do you agree to undergo a full medical including a drug & alcohol screen at the company’s expense? *Yes No

D&D Group ensures employees are unimpared whilst at work. Will you participate in a random ‘on the job’ Alcohol & Drug test? *Yes No

Are you currently restricted / have any issues to any of the following work

At Heights *Yes No

Dirty/Wet work *Yes No

In a noisy environment *Yes No

In Confined (small) Spaces *Yes No

Heavy Work *Yes No

In a dusty environment *Yes No

If the answer to any of the above is Yes, please detail the present restrictions and when they might be lifted, if not permanent

Have you ever suffered or are you suffering from

Sore eyes or skin rashes due to oils, chemicals, animal or plant products? *Yes No

Are you currently taking / using

Any medications that have been prescribed by a doctor? *Yes No

Any medications that have been bought over the counter? *Yes No

Recreational drugs? *Yes No

7. General Company Matters

Given the nature of our business, you may be required to work with various host employers in different industries, on different work sites at different times. We require the following information to assist us and ensure you are placed in a suitable position.

Are you willing and able to work overtime? *Yes No

Are you willing and able to work weekends? *Yes No

Are you willing and able to work varied shifts? *Yes No

If not, what shifts are you able to work?

Day Shift *Yes No

Afternoon Shift *Yes No

Night Shift *Yes No

Are you willing and able to work at short notice? *Yes No

Are you willing to attend safety inductions in your own time? *Yes No

Are you prepared to work to the full extent of your capabilities? *Yes No

8. Driver Declaration

Have you had any insurance cancelled or refused *Yes No

Have you had any special conditions imposed or renewal not offered *Yes No

Have you had any claims *Yes No

Have you had any fines *Yes No

Have you lost your licence *Yes No

Provide details if yes to any of the above

9. Workers Compensation History

Have you made any previous Workers Compensation Claims? *Yes No

Claim Details

Date of Injury

Name of Employer

Address of Employer

Nature of Injury

How did Injury Occur

Name of Insurer

Duration of Absence of Work

Has Claim been resolved?
Yes No

Was there an award made in your favour for permanent impariment in respect of the claim?
Yes No

If so, what loss or losses?

Hearing

Have you ever been exposed to loud noise? *Yes No

If yes, please give details

Do you suffer from any hearing loss/impairment? *Yes No

If yes, please state

Have you made any claim under the Workers Compensation Act for hearing loss or industrial deafness? *Yes No

If so, against whom was the claim made?

Has the claim been resolved?
Yes No

What, if known to you, is your present level of binaural hearing loss

Are you willing to undergo a medical examination to assess your present level of hearing loss? *Yes No

12. Supporting Information

Please attach any additional certifications, tickets, licences and / or resume to support your application.

Attachment

Attachment

Attachment

13. How did you hear about D&D Employment Services

Advertising *Yes No

Word of Mouth *Yes No

Website *Yes No

D&D Employee *Yes No

Comment

14. Application Declaration

* I certify that the answers, information and statements made in this application form are correct and to the best of my knowledge.

* I understand this information may be subject to verification and I authorize the company to approach any and all third parties identified by me and included in this application for this purpose. I hereby authorize all third parties specifically identified by me in this application to release to the company such information as it may reasonably require verifying the information that I have disclosed in this application.

* I understand that to supply information, which is false or misleading as part of this application is extremely serious. I understand that to be employed on the basis of falsified or misleading information would subsequently give the company grounds to immediately terminate my employment.